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Schedwin M, Bisumba Furaha A, Elimian K, King C, Malembaka EB, Yambayamba MK, Tylleskär T, Alfvén T, Carter SE, Welo Okitayemba P, Mapatano MA, Hildenwall H. Facility capacity and provider knowledge for cholera surveillance and diarrhoea case management in cholera hotspots in the Democratic Republic of Congo - a mixed-methods study. Glob Health Action 2024; 17:2317774. [PMID: 38441883 PMCID: PMC10916892 DOI: 10.1080/16549716.2024.2317774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/08/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Wider healthcare-strengthening interventions are recommended in cholera hotspots and could benefit other types of diarrhoeal diseases which contribute to greater mortality than cholera. OBJECTIVE Describe facility capacity and provider knowledge for case management of diarrhoea and cholera surveillance in cholera hotspots in the Democratic Republic of Congo (DRC) among health facilities, drug shops, and traditional health practitioners. METHODS We conducted a sequential exploratory mixed-method study, using focus group discussions, facility audits, and provider knowledge questionnaires during September and October 2022 in North Kivu and Tanganyika provinces, Eastern DRC. Content analysis was used for qualitative data. Quantitative data were summarised by facility level and healthcare provider type. Audit and knowledge scores (range 0-100) were generated. Multivariable linear regression estimated association between scores and explanatory factors. Qualitative and quantitative data were triangulated during interpretation. RESULTS Overall, 244 facilities and 308 providers were included. The mean audit score for health facilities was 51/100 (SD: 17). Private facilities had an -11.6 (95% CI, -16.7 to -6.6) lower adjusted mean score compared to public. Mean knowledge score was 59/100 (95% CI, 57 to 60) for health facility personnel, 46/100 (95% CI, 43 to 48) for drug shop vendors and 37/100 (95% CI, 34 to 39) for traditional health practitioners. Providers had particularly low knowledge concerning when to check for low blood sugar, use of nasogastric tubes, and dosing schedules. Knowledge about case definitions for cholera was similar between groups (range 41-58%) except for traditional health practitioners for the definition during an outbreak 15/73 (21%). CONCLUSIONS Increasing awareness of cholera case definitions in this context could help improve cholera surveillance and control. Increased support and supervision, especially for private providers, could help ensure facilities are equipped to provide safe care. More nuanced aspects of case management should be emphasised in provider training.
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Affiliation(s)
- Mattias Schedwin
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Aurélie Bisumba Furaha
- Paediatric Department, Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Kelly Elimian
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Exhale Health Foundation, Abuja, Nigeria
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Center for Tropical Diseases and Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Marc K Yambayamba
- Department of Epidemiology and Biostatistics, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
- Section Epidemiology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Thorkild Tylleskär
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Tobias Alfvén
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Sach’s Children and Youth Hospital, Stockholm, Sweden
| | - Simone E Carter
- Public Health Emergencies, UNICEF, Kinshasa, Democratic Republic of Congo
| | - Placide Welo Okitayemba
- Programme National d’Elimination du Choléra et de lutte contre les autres Maladies Diarrhéiques, Ministry of Health, Kinshasa, Democratic Republic of Congo
| | - Mala Ali Mapatano
- Department of Nutrition, Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Helena Hildenwall
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Malembaka EB, Bugeme PM, Hutchins C, Xu H, Hulse JD, Demby MN, Gallandat K, Saidi JM, Rumedeka BB, Itongwa M, Tshiwedi-Tsilabia E, Kitoga F, Bodisa-Matamu T, Kavunga-Membo H, Bengehya J, Kulondwa JC, Debes AK, Taty N, Lee EC, Lunguya O, Lessler J, Leung DT, Cumming O, Okitayemba PW, Mukadi-Bamuleka D, Knee J, Azman AS. Effectiveness of one dose of killed oral cholera vaccine in an endemic community in the Democratic Republic of the Congo: a matched case-control study. Lancet Infect Dis 2024; 24:514-522. [PMID: 38246191 PMCID: PMC11043051 DOI: 10.1016/s1473-3099(23)00742-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/07/2023] [Accepted: 11/21/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND A global shortage of cholera vaccines has increased the use of single-dose regimens, rather than the standard two-dose regimen. There is sparse evidence on single-dose protection, particularly in children. In 2020, a mass vaccination campaign was conducted in Uvira, an endemic urban setting in eastern Democratic Republic of the Congo, resulting in largely single-dose coverage. We examined the effectiveness of a single-dose of the oral cholera vaccine Euvichol-Plus in this high-burden setting. METHODS In this matched case-control study, we recruited individuals with medically attended confirmed cholera in the two cholera treatment facilities in the city of Uvira. The control group consisted of age-matched, sex-matched, and neighbourhood-matched community individuals. We recruited across two distinct periods: Oct 14, 2021, to March 10, 2022 (12-17 months after vaccination), and Nov 21, 2022, to Oct 18, 2023 (24-36 months after vaccination). Study staff administered structured questionnaires to all participants to capture demographics, household conditions, potential confounding variables, and vaccination status. The odds of vaccination for the case and control groups were contrasted in conditional logistic regression models to estimate unadjusted and adjusted vaccine effectiveness. FINDINGS We enrolled 658 individuals with confirmed cholera and 2274 matched individuals for the control group. 99 (15·1%) individuals in the case group were younger than 5 years at the time of vaccination. The adjusted single-dose vaccine effectiveness was 52·7% (95% CI 31·4 to 67·4) 12-17 months after vaccination and 44·7% (24·8 to 59·4) 24-36 months after vaccination. Although protection in the first 12-17 months after vaccination was similar for children aged 1-4 years and older individuals, the estimate of protection in children aged 1-4 years appeared to wane during the third year after vaccination (adjusted vaccine effectiveness 32·9%, 95% CI -30·7 to 65·5), with CIs spanning the null. INTERPRETATION A single dose of Euvichol-Plus provided substantial protection against medically attended cholera for at least 36 months after vaccination in this cholera-endemic setting. Although the evidence provides support for similar levels of protection in young children and others in the short term, protection among children younger than 5 years might wane significantly during the third year after vaccination. FUNDING Wellcome Trust and Gavi, the Vaccine Alliance.
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Affiliation(s)
- Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Centre for Tropical Diseases and Global Health (CTDGH), Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Patrick Musole Bugeme
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Centre for Tropical Diseases and Global Health (CTDGH), Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Chloe Hutchins
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Hanmeng Xu
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Juan Dent Hulse
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Maya N Demby
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Karin Gallandat
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Jaime Mufitini Saidi
- Ministère de la Santé Publique, Hygiène et Prévention, Zone de Santé d'Uvira, Uvira, Democratic Republic of the Congo
| | | | | | | | - Faida Kitoga
- Rodolphe Merieux INRB-Goma Laboratory, Goma, North Kivu, Democratic Republic of the Congo
| | - Tavia Bodisa-Matamu
- Rodolphe Merieux INRB-Goma Laboratory, Goma, North Kivu, Democratic Republic of the Congo
| | - Hugo Kavunga-Membo
- Rodolphe Merieux INRB-Goma Laboratory, Goma, North Kivu, Democratic Republic of the Congo; Institut National de Recherche Biomédicale, INRB, Kinshasa, Democratic Republic of the Congo
| | - Justin Bengehya
- Ministère de la Santé Publique, Hygiène et Prévention, Division Provinciale de la Sante' Publique du Sud-Kivu, Bukavu, Democratic Republic of the Congo
| | - Jean-Claude Kulondwa
- Ministère de la Santé Publique, Hygiène et Prévention, Division Provinciale de la Sante' Publique du Sud-Kivu, Bukavu, Democratic Republic of the Congo
| | - Amanda K Debes
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA
| | - Nagède Taty
- PNECHOL-MD, Community IMCI, Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Elizabeth C Lee
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Octavie Lunguya
- Institut National de Recherche Biomédicale, INRB, Kinshasa, Democratic Republic of the Congo; Service of Microbiology, Department of Medical Biology, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; University of North Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel T Leung
- Division of Infectious Diseases and Division of Microbiology and Immunology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Daniel Mukadi-Bamuleka
- Rodolphe Merieux INRB-Goma Laboratory, Goma, North Kivu, Democratic Republic of the Congo; Institut National de Recherche Biomédicale, INRB, Kinshasa, Democratic Republic of the Congo; Service of Microbiology, Department of Medical Biology, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jackie Knee
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Geneva Centre for Emerging Viral Diseases and Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland.
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Xu H, Zou K, Dent J, Wiens KE, Malembaka EB, Bwire G, Okitayemba PW, Hampton LM, Azman AS, Lee EC. Enhanced cholera surveillance to improve vaccination campaign efficiency. Nat Med 2024; 30:1104-1110. [PMID: 38443690 PMCID: PMC11031394 DOI: 10.1038/s41591-024-02852-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Abstract
Systematic testing for Vibrio cholerae O1 is rare, which means that the world's limited supply of oral cholera vaccines (OCVs) may not be delivered to areas with the highest true cholera burden. Here we used a phenomenological model with subnational geographic targeting and fine-scale vaccine effects to model how expanding V. cholerae testing affected impact and cost-effectiveness for preventive vaccination campaigns across different bacteriological confirmation and vaccine targeting assumptions in 35 African countries. Systematic testing followed by OCV targeting based on confirmed cholera yielded higher efficiency and cost-effectiveness and slightly fewer averted cases than status quo scenarios targeting suspected cholera. Targeting vaccine to populations with an annual incidence rate greater than 10 per 10,000, the testing scenario averted 10.8 (95% prediction interval (PI) 9.4-12.6) cases per 1,000 fully vaccinated persons while the status quo scenario averted 6.9 (95% PI 6.0-7.8) cases per 1,000 fully vaccinated persons. In the testing scenario, testing costs increased by US$31 (95% PI 25-39) while vaccination costs reduced by US$248 (95% PI 176-326) per averted case compared to the status quo. Introduction of systematic testing into cholera surveillance could improve efficiency and reach of global OCV supply for preventive vaccination.
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Affiliation(s)
- Hanmeng Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kaiyue Zou
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juan Dent
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kirsten E Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, PA, USA
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Tropical Diseases and Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Godfrey Bwire
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Placide Welo Okitayemba
- Programme National d'Elimination de Choléra et lutte contre les autres Maladies Diarrhéiques, Kinshasa, Democratic Republic of the Congo
| | | | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Elizabeth C Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Schedwin M, Furaha AB, Hildenwall H, Elimian K, Malembaka EB, Yambayamba MK, Forsberg BC, Van Damme W, Alfvén T, Carter SE, Okitayemba PW, Mapatano MA, King C. Exploring different health care providers´ perceptions on the management of diarrhoea in cholera hotspots in the Democratic Republic of Congo: A qualitative content analysis. PLOS Glob Public Health 2024; 4:e0002896. [PMID: 38502678 PMCID: PMC10950234 DOI: 10.1371/journal.pgph.0002896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Abstract
Global cholera guidelines support wider healthcare system strengthening interventions, alongside vertical outbreak responses, to end cholera. Well-trained healthcare providers are essential for a resilient health system and can create synergies with childhood diarrhoea, which has higher mortality. We explored how the main provider groups for diarrhoea in cholera hotspots interact, decide on treatment, and reflect on possible limiting factors and opportunities to improve prevention and treatment. We conducted focus group discussions in September 2022 with different healthcare provider types in two urban and two rural cholera hotspots in the North Kivu and Tanganyika provinces in the Eastern Democratic Republic of Congo. Content analysis was used with the same coding applied to all providers. In total 15 focus group discussions with medical doctors (n = 3), nurses (n = 4), drug shop vendors (n = 4), and traditional health practitioners (n = 4) were performed. Four categories were derived from the analysis. (i) Provider dynamics: scepticism between all cadres was prominent, whilst also acknowledging the important role all provider groups have in current case management. (ii) Choice of treatment: affordability and strong caregiver demands shaped by cultural beliefs strongly affected choice. (iii) Financial consideration on access: empathy was strong, with providers finding innovative ways to create access to treatment. Concurrently, financial incentives were important, and providers asked for this to be considered when subsiding treatment. (iv) How to improve: the current cholera outbreak response approach was appreciated however there was a strong wish for broader long-term interventions targeting root causes, particularly community access to potable water. Drug shops and traditional health practitioners should be considered for inclusion in health policies for cholera and other diarrhoeal diseases. Financial incentives for the provider to improve access to low-cost treatment and investment in access to potable water should furthermore be considered.
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Affiliation(s)
- Mattias Schedwin
- Department of Global Public Health, Stockholm, Sweden
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Aurélie Bisumba Furaha
- Paediatric Department, Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Helena Hildenwall
- Department of Global Public Health, Stockholm, Sweden
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Karolinska Institutet, Intervention and Technology, Stockholm, Sweden
| | - Kelly Elimian
- Department of Global Public Health, Stockholm, Sweden
- Exhale Health Foundation, Abuja, Nigeria
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Tropical Diseases and Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Marc K. Yambayamba
- Vetsuisse Faculty, Section Epidemiology, University of Zurich, Zurich, Switzerland
- Department of Epidemiology and Biostatistics, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | | | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Tobias Alfvén
- Department of Global Public Health, Stockholm, Sweden
- Sach’s Children and Youth Hospital, Stockholm, Sweden
| | - Simone E. Carter
- Public Health Emergencies, UNICEF, Kinshasa, Democratic Republic of Congo
| | - Placide Welo Okitayemba
- Programme National d’Elimination du Choléra et de Lutte Contre les Autres Maladies Diarrhéiques, Kinshasa, Democratic Republic of Congo
| | - Mala Ali Mapatano
- Department of Nutrition, Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Carina King
- Department of Global Public Health, Stockholm, Sweden
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Hounmanou YMG, Njamkepo E, Rauzier J, Gallandat K, Jeandron A, Kamwiziku G, Porten K, Luquero F, Abedi AA, Rumedeka BB, Miwanda B, Michael M, Okitayemba PW, Saidi JM, Piarroux R, Weill FX, Dalsgaard A, Quilici ML. Genomic Microevolution of Vibrio cholerae O1, Lake Tanganyika Basin, Africa. Emerg Infect Dis 2023; 29:149-153. [PMID: 36573719 PMCID: PMC9796204 DOI: 10.3201/eid2901.220641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Africa's Lake Tanganyika basin is a cholera hotspot. During 2001-2020, Vibrio cholerae O1 isolates obtained from the Democratic Republic of the Congo side of the lake belonged to 2 of the 5 clades of the AFR10 sublineage. One clade became predominant after acquiring a parC mutation that decreased susceptibility to ciprofloxacin.
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